This measure of best clinical practice is monitored on a regular basis by the appropriate hospital and medical staff. Our goal is to deliver care at or above the National Top 10% performing hospitals. When performing below our goal, we implement improvement tools and methodologies to improve care. PDCA ("Plan-Do-Check-Act") is an iterative four-step problem-solving process that is typically used.

PLAN: In this step, we evaluate the problem and propose solutions. Examples include education, development or modifications of standardized protocols, creating "prompts" or reminders, and using beneficial technology.

DO: We then implement the new process(es). Often on a small scale if possible.

CHECK: Next we measure the new process(es) and compare the results against the expected results to ascertain any differences.

ACT: Finally, we analyze the differences to determine their cause and where to apply changes that will include improvement. When a pass through these four steps does not result in the need to improve, we refine the scope to which PDCA is applied until there is a plan that involves improvement. Improvement often involves multiple PDCA cycles.